11.The nurse is taking care of a patient status post rightcarotid endarterctomy (CEA). Which of the following assessmentfindings needs to be reported to the surgeon immediately?
A. Mild throat pain 3/10 B. Bruises along the incision line C.Tongue midline D. Persistent Headache
12. A patient newly diagnosed with an ishemic stroke is acandidate for treatment with tissue plasminogen activator. Duringthe transfusions of tpa, the nurse assessed the patient forpossible signs of hemorrhagic stroke. Which action should the nurseimplement first?
a. call rapid response team b. prepare the patient forcraniotomy c. schedule a stat ct scan of the head d. turn off thetpa infusion
13. The nurse is assessing a patient on the inpatientpsychiatric unit. Which statement by the patient would indicatethis patient is experiencing is delusion? a. I feel bugs crawlingall over my legs b. There is a rat living in my stomach c. I cansmell rotting meat in my room d. My breakfast tastes like bugspray
14. The nurse is performing an admission assessment on a patientwho is suspected of having a neurocognitive disorder: Alzheimersdementia. Which of the following would the nurse include in thesubjective questionnaire for dementia?
A. Testing the patients ability to think abstractly B. Askingthe patient to spell WORLD backwards C. Questioning the patient orfamily about changes in memory D. Assessing the patient’s abilityto remember unrelated words
15. A patient in a locked unit has been staring at a staffmember, pacing with clenched fists and talking under his breath.What should the nurse interpret the behavior to mean?
a. The patient feels threatened by the staff member and maybecome violent b. The patient is having auditory hallucinations c.The patient wants to speak with staff but Is unable to organizethoughts d. The patient is having visual hallucinations
16. A patient with aphasia presents to the emergency room with asuspected ischemic. Which of the following nursing interventionsshould be included in the plan of care?
a. use clear and simple language when talking to the patients b.support the week arm and leg with pillows c. request physicaltherapist for evaluation d. offer small frequent meals withprecaution of aspiration
17. A patient with antisocial personality disorder asks to makea phone call at 10:05 pm to his lawyer regarding his court case.There are no phone calls after 10 pm on the unit. Which responsemade by the nurse is the most therapeutic?
a. You know the rules, I am very surprised at your behaviors b.There no calls after 10 pm, you will be able to call tomorrow c.Lets discuss why this phone call is so important, I know you areanxious d. I understand this is important to you. Go ahead and makea quick phone call
18. A patient begins to experience a tonic-clonic seizure whichof the following interventions should be included in the plan ofcare?
a. restrain the patient b. place a padded tongue blade in thepatients mouth c. turn the patient on the side d. remove theclothing that the patient is wearing
19. A patient states” I can see two angels talking in the cornerof my room. They are saying I am going to hell because I am aterrible person.” What is the most therapeutic statement made bythe nurse?
a. what do they look like? What are they telling you? b. I don’tsee two angels. They must be frightening for you? c. Tell me moreabout the two angels. That sounds very scary d. I doubt that. Whatmakes you think this could be true
20. A nurse is working on an inpatient psychiatric unit isobserving a recently admitted patient with a diagnosis ofschizophrenia. When assessing for negative symptoms what would thenurse observe the patient for?
a. observation of the patient talking to himself b. mimics themovements of the nurse during the admission assessment c. Show lackof interest in any of the groups or unit activities d. Answers inword salad when asked a question by the nurse
21. A new nurse working in the psychiatric emergency room inbeing oriented to assessing risk factors for potential violence.What statement made by the new nurse shows further understanding isneeded?
a. a diagnosis such as alzheimers can increase the risk ofviolence b. a past history of violence does not indicate a futurerisks for violence c. a patients current behavior is predictive ofthe risk for violence d. clenched fists, cursing and yelling areindicators of potential violence
22. While waiting to see the psychiatrist a patient slams hishand on the counter and demands to see the doctor now? Whichnursing interventions should the nurse implement to address thisbehavior?
A. assess the patient with deep breathing awareness to calm downb. In a calm voice tell the patient the doctor will arrive soon c.set firm limits on behavior with the support of staff d. offer POPRN, medications to reduce agitation
23. A patient with myasthenia gravis is admitted to the hospitalwith respiratory insufficiency and severe weakness. When will adiagnosis of myasthenia crisis be made?
a. administration of Tensilon did not increase musclecontractility b. Administration of a cholinterase inhibitor did notimprove the symptoms c. Administration of Tensilon increased musclecontractibility d. Administration of an anticholinergic medicationimproved symptoms
24. A patient diagnosed with bells palsy is being cared for anoutpatient basis. During health education the nurse should promotewhich of the following actions?
a. applying a protective eye shield at night b. chewing slowlyon affected side while eating c. Avoiding using an electric toothbrush d. Practicing wrinkling forehead
25. The emergency department nurse is assessing and monitoringthe patient with a gun shot wound to the middle of the back.Because the patient is at risk for spinal shock, What does thenurse monitor for?
a. paralytic lieus and loss of bowel and bladder b. increasedrespiratory rate and loss of reflex activity c. decreased bloodpressure, tachycardia and flaccid paralysis d. tachycardia and achange in the level of consciousness
26. A patient with Guillan Barre Syndrome has experienced asharp decline in vital capacity. What is the nurse’s mostappropriate action?
a. administer broncodilators STAT b. Administer 100% 02 via maskc. Prepare to assist with BIPAP d. Prepare to assist withintubation
27. A nurse is studying crisis and crisis intervention. Whichstatement by the student shows further understanding about crisisneeded?
a. how an individual responds to a crisis is based on how theyview the event b. life transition crisis may be expected but theperson feels lack of control c. in a crisi from traumatic stressthe individual does not seek treatment right away after thetraumatic event d. dispositional crisis is related to an internalstressor and requires long term psychotherapy
28. The nurse is assessing an alert and oriented x4 elderly malefrom a nursing home in the emergency department. The patient has adislocated shoulder, black eye, and abrasions on his face and head.The nurse documents the injuries on the body sheet. What should thenurse do next?
a. assure the patient he is safe and take photographs of theinjuries b. Notify the physician regarding concerns about suspectedabuse c. Ask the patient what happened that brought him to theemergency room d. Contact the nursing home and inquire about theinjuries
29. A nurse observes a psychotic patient who is gesturing at afigure on the television and is becoming increasingly agitated.Which interventions should be initiated by the nurse . select allthat apply.
a. orient patient to reality b. in a firm voice instruct thepatient to stop the behavior c. recognize the patients behavior asa delusion d. use therapeutic touch to ensure they are safe e. givesimple commands in a calm voice
30. The nurse is talking to a female patient who is a survivorof intimate partner violence. The woman relates that her husbandhas been in jail many times and has been told he has an antisocialpersonality disorder. The nurse interprets this information andsuspects that the woman’s husband would most likely demonstratewhich personality characteristics?
a. blames others for his actions, is impulsive and takesadvantage of others b. is cold and detached, avoids closerelationships and appears indifferent to praise c. is cautious andwary and does not reveal his personality or otherwise make himselfd. has symptoms of depression along while harboring feelings ofinadequacy
